Are we getting closer to treating heart and mind together and bridging the gap for individual patients attending cardiac rehabilitation?

This editorial refers to ‘Cognitive–behavioural therapy reduces psychological distress in younger patients with cardiac disease: a randomized trial’, by A. Holdgaard et al., https://doi.org/10.1093/eurheartj/ehac792. Example of a stepped care model for cardiovascular disease patients with psychological distress or clinical anxiety and/or depression. There is considerable evidence that heart and mind go hand in hand.1 Thus, we need not only to treat the underlying heart disease but also to identify and address psychological and psychosocial issues, as they comprise barriers for adherence to cardiac rehabilitation (CR), lifestyle changes, smoking cessation, etc. In addition, patients with heart disease and comorbid depression cost society 33% more2 as compared with patients with heart disease alone, and are at greater risk of premature death.3 In addition, psychosocial factors (e.g. anxiety, depression, and loneliness) contribute to improved risk prediction above and beyond traditional risk factors and serve as risk modifiers.4 The 2021 European guidelines on cardiovascular disease prevention emphasize the importance of dealing with psychosocial risk factors,4 which is also supported in a recent clinical consensus statement on factors influencing adherence.5 The aim of the study by Holdgaard6 and colleagues published in this issue of the European Heart Journal was to test if brief group-based cognitive–behavioural therapy (CBT)—with five sessions of 2 h—delivered by nurses trained in CBT, and added to usual CR, reduced psychological distress in patients with symptoms of anxiety and/or depression as compared with CR alone. The authors found that adding a group-based CBT intervention to CR in patients with psychological distress led to a significantly greater reduction in symptoms of anxiety and depression at 3 and 6 months follow-up compared with CR alone. The intervention group showed greater adherence to CR, improved heart-related quality of life at 6 but not at 3 months follow-up, and had a lower risk of cardiac readmission after 12 months compared with CR alone. No statistically significant intervention effect was found on risk factor control or return to work. The study by Holdgaard and colleagues is timely, and the authors are to be commended for pursuing a new avenue by evaluating whether brief group-based CBT delivered by cardiac nurses, supervised by a psychologist, and combined with standard CR, is feasible and effective in patients with heart disease. In our experiences from the eMindYourHeart feasibility study7 and the ongoing eMindYourHeart trial,8 it is particularly important to integrate psychological treatment into CR. Even though Danish patients are screened systematically for anxiety and depression in the CR setting according to a Danish national clinical guideline,9 there is a great risk that patients ‘fall between two chairs’ if they are responsible themselves for acting and contacting their general practitioner or a mental health professional because of a score on anxiety and/or depression that warrants treatment. In particular, vulnerable patients with depression and living alone are at greater risk of not finding their own way to treatment because of these challenges. Hence, the key strength of this study is that the authors demonstrate that adding and integrating a psychological intervention component into the existing CR framework is a feasible and efficacious way of helping distressed heart patients to ameliorate their psychological well-being. The design of the study, however, gives rise to some concerns, including the mixture of patients with either coronary artery disease (CAD) or valvular heart disease, as these patients are potentially quite different. In addition, patients were only recruited from the Capital Region—one of the five regions in Denmark—and the intervention was tested on a rather selected group of patients. The authors point out that 46% of eligible CAD patients were referred to CR in the region. From the patients attending CR, the study excluded patients aged 65 or older if not occupationally active, patients with a left ventricular ejection fraction (LVEF) <35%, and more severely distressed patients including patients receiving psychoactive drugs such as selective serotonin reuptake inhibitors (SSRIs). Taken together, this narrows the range of patients to which the promising results from the study can reliably be generalized, suggesting the need to broaden the scope of available interventions targeting different subsets of patients. The primary endpoint of the study was psychological distress measured with the mean change in the Hospital Anxiety and Depression Scale (HADS) total score from baseline to 3 months follow-up. The validity of employing the total HADS score as a generic measure of psychological distress is debatable, with most studies finding a two-factor or three-factor solution to be the best psychometric fit for the HADS in cardiac populations, although some authors have argued that the HADS total score reflects general psychological distress.10 The authors’ definition of a minimal clinically important difference (MCID) of 1.7 points on the HADS as an indicator of treatment success is questionable, as the identification of this MCID value is based on the subscales (each ranging from 0 to 21) as opposed to the total score (ranging from 0 to 42). To our knowledge, however, no previous studies have determined the MCID for the HADS total score in cardiac patients. Irrespectively, the authors find an effect of >3 points on the HADS total score between patients in the intervention vs. the control group. We consider the use of cardiac nurses as one of the strengths of the study, as there is often overlap between symptoms of heart disease, anxiety, and depression, which calls for a thorough understanding of how mental and somatic symptoms overlap and interact to ensure the proper treatment for patients. However, we are somewhat sceptical about the authors’ conclusion that their intervention is feasible to implement in the Danish healthcare system at present due to a shortage of nurses. In the article, it is not clear if the authors’ nurse-delivered CBT treatment aims to treat anxiety and depression or psychological distress, as the terms are used interchangeably. Differentiating general psychological distress from clinical diagnoses of anxiety and depression is important, as it has a bearing on for which patients it will be sufficient to have a brief group-based intervention and which patients will need more comprehensive treatment. To be included in the study, patients had to score a minimum of 8 on either anxiety or depression on the HADS. If a patient scored 11 or higher on depression, they had to undergo a psychiatric evaluation to decide if they would be eligible for the treatment. In the study, 57/233 (24%) of patients were excluded following the psychiatric evaluation. Given the cut-offs of HADS for both anxiety and depression (0–7 normal; 8–10 mild; 11–14 moderate, 15–21 severe11) and that a score of 11 on depression led to exclusion, this suggests that the CBT treatment is intended for low levels of psychological distress and not clinical diagnoses of anxiety and/or depression. As resources in the healthcare sector and CR are limited, a stepped care approach to treating mental health issues in patients with heart disease may be the best way to meet patients’ needs for treatment. A stepped care model of intervention for mental health issues essentially consists of a ladder with several treatment steps that increase in complexity and costs, as a patient ‘climbs’ the ladder. Essentially, this model ensures that treatment is adapted to patients’ needs ­but also that patients are not ‘overtreated’. The stepped care model has also been shown to be cost-effective.12 When designing a stepped care system, several factors need to be considered including (i) which steps the treatment ladder will include, (ii) how it is decided which treatment step a patient should begin with, and (iii) how it is decided when a patient should move up to a more complex treatment step or not receive any more treatment. These factors are important to consider, as not doing so can result in the stepped care model of treatment being a more expensive and/or less effective solution than existing treatment system structures.13 We propose a stepped care model with five steps (i.e., 2–6) for treating patients with heart disease and comorbid mental health issues, which could be structured as shown in Figure 1. The study by Holdgaard et al. shows promising results of integrating a brief nurse-led CBT intervention into CR. Targeting mental health and integrating it as a part of CR is essential, as it may also reduce stigma that some patients still have with respect to seeking help for psychological distress. It could be seen as an ‘Integrated CR package’ geared to all risk factors including the psychological. While this may prove to be a useful piece of the puzzle, a wider perspective and additional treatment options are warranted to fulfil the psychological needs of the broad range of patients enrolled in CR. We suggest a stepped care framework with evidence-based interventions at each step matched to fit the individual patient. Offering different modes of delivery, i.e. face-to-face, eHealth-based, or a combination (blended care), should be considered as this gives patients a choice and may enhance adherence as compared with using a one-size-fits all approach. Unfortunately, this still leaves one challenge, as also seen in the study of Holdgaard et al. and other studies,14 which is suboptimal referral of patients to CR and many patients who drop out. All authors declare no funding for this contribution.